Nonspecific ulcerative colitis

Ulcerative colitis is a chronic ulcerative-inflammatory disease of the mucous membrane of the colon, which is characterized more often by bloody diarrhea. Extraintestinal symptoms of ulcerative colitis, especially arthritis, can be observed. The long-term risk of developing colon cancer is high. The diagnosis is made with a colonoscopy. Treatment of non-specific ulcerative colitis includes 5-ASA, glucocorticoids, immunomodulators, anticytokines, antibiotics and sometimes surgical treatment.

[1], [2]

What causes nonspecific ulcerative colitis?

The causes of nonspecific ulcerative colitis are unknown. Presumptive etiological factors are infection ( viruses, bacteria ), irrational nutrition (a diet low in dietary fiber). Many people consider the last factor as predisposing to the development of the disease.

Causes of nonspecific ulcerative colitis

Ulcerative colitis usually begins with the rectum. The disease can be limited only to the rectum (ulcerative proctitis) or progress in the proximal direction, sometimes involving the entire large intestine. Rarely affects the whole large intestine.

Inflammation with ulcerative colitis captures the mucous membrane and the submucosa, and between the normal and affected tissue a clear boundary remains. Only in severe cases, the muscle layer is involved in the process. In the early stages, the mucosa looks erythematous, finely granulated and loose with a loss of normal vascular pattern and often with disordered hemorrhage zones. Large ulceration of the mucosa with abundant purulent exudate characterizes the severe course of the disease. Islets with respect to normal or hyperplastic inflamed mucous membrane (pseudopolyps) protrude above zones of ulcerated mucous membrane. The formation of fistulas and abscesses is not observed.

Fulminant colitis develops in the case of transmural ulceration, in which local ileus and peritonitis develop. During the period from several hours to several days the large intestine loses muscle tone and begins to be dilated.

A toxic megacolon (or toxic dilatation) refers to an emergency pathology in which severe transmural inflammation leads to colon dilatation and sometimes perforation. This often occurs when the transverse diameter of the large intestine exceeds 6 cm during the exacerbation period. This condition usually occurs spontaneously during very severe colitis, but can be triggered by opiates or anticholinergic antidiarrheal drugs. Perforation of the colon significantly increases lethality.

Pathogenesis of nonspecific ulcerative colitis

Symptoms of nonspecific ulcerative colitis

Bloody diarrhea of varying intensity and duration alternates with asymptomatic intervals. Usually exacerbation begins acutely with frequent desires for defecation, moderate cramping pains in the lower abdomen, blood and mucus in the stool are found. Some cases develop after infections (eg, amebiasis, bacterial dysentery).

If ulceration is limited to the recto-sigmoid department, the stool may be normal, dense and dry, but mucus may be secreted between the rectum stools and an admixture of erythrocytes and leukocytes. Common symptoms of ulcerative colitis are absent or mild. If ulceration progresses in the proximal direction, the stool becomes more fluid and becomes more frequent 10 times a day or more with severe spastic pains and anxious patients with tenesmus, including at night. The stool can be watery and contain mucus and often consists almost entirely of blood and pus. In severe cases, within a few hours patients may lose a lot of blood that requires urgent transfusion.

Fulminant colitis is manifested by sudden severe diarrhea, fever up to 40 C, abdominal pain, signs of peritonitis (eg, protective tension, peritoneal symptoms) and severe toxemia.

Common symptoms of ulcerative colitis are more characteristic of severe disease and include malaise, fever, anemia, anorexia, and weight loss. Extraintestinal manifestations (especially on the part of the joints and skin) always occur in the presence of general symptoms.

Symptoms of nonspecific ulcerative colitis

Diagnosis of nonspecific ulcerative colitis

[3], [4], [5], [6], [7], [8]

Initial manifestations of nonspecific ulcerative colitis

The diagnosis is expected in the development of typical symptoms and signs, especially if the disease is accompanied by extraintestinal manifestations or similar episodes in the anamnesis. Ulcerative colitis should be differentiated from Crohn's disease and other causes of acute colitis (eg, infection, in elderly patients ischemia).

In all patients, it is necessary to examine the stool for intestinal pathogens, and Entamoeba histolytica must be excluded from the stool immediately after emptying. In case of suspicion of amoebiasis, arrivals from epidemiological areas should be examined for serological titres and biopsy samples. With a previous use of antibiotics or recent hospitalization, it is necessary to perform stool studies for Clostridium difficile toxin . Patients at risk should be screened for HIV, gonorrhea, herpes virus, chlamydia and amoebiasis. In patients taking immunosuppressive drugs, opportunistic infections (eg, cytomegalovirus, Mycobacterium avium-intracellulare) or Kaposi's sarcoma should be excluded . The development of colitis is possible in women using oral contraceptives; Such colitis is usually resolved spontaneously after the exclusion of hormone therapy.

Sigmoscopy should be performed ; this study allows you to visually confirm the colitis and directly take the culture for bacteriological inoculation and microscopic evaluation, as well as for biopsy of the affected areas. However, both visual examination and biopsy may be uninformative in the diagnosis, since similar lesions occur with different types of colitis. Severe perianal lesions, impaired rectal function, no bleeding, and asymmetric or segmental lesions of the colon indicate Crohn's disease, not ulcerative colitis. Do not immediately perform a colonoscopy; it should be performed according to the indications in case of inflammation spreading to the proximal intestine parts beyond the reach of the sigmoidoscope.

It is necessary to perform laboratory studies to identify anemia, hypoalbuminemia and electrolyte imbalance. Functional hepatic tests can reveal an increase in the level of alkaline phosphatase and y-glutamyltranspeptidase, which suggest a possible development of primary sclerosing cholangitis. Perinuclear antineutrophil cytoplasmic antibodies are relatively specific (60-70%) for ulcerative colitis. Anti- Saccharomyces cerevisiae antibodies are relatively specific for Crohn's disease. However, these tests definitely do not differentiate these two diseases and are not recommended for routine diagnosis.

X-ray studies are not diagnostic, but sometimes they allow us to identify abnormalities. Conventional radiography of the abdominal cavity can visualize mucosal edema, loss of gaustration and the absence of a formed stool in the affected bowel. Irrigoscopy indicates similar changes, but more clearly, and can also demonstrate ulceration, but it should not be performed in the acute period of the disease. A short, rigid colon with an atrophic or pseudopolypositive mucosa is often observed after several years of the disease. X-ray signs "fingerprint" and segmental lesions more indicate intestinal ischemia or, possibly, Crohn's colitis than ulcerative colitis.

Recurrent symptoms of nonspecific ulcerative colitis

Patients with an established diagnosis of the disease and relapse of typical symptoms should be examined, but a broad study is not always required. Depending on the duration and severity of the symptoms, sigmoidoscopy or colonoscopy and a general blood test can be performed. Bacteriological studies of the stool on the microflora, eggs and parasites and studies on C. Difficile toxin should be carried out in case of atypical signs of relapse or enhancement of symptoms after prolonged remission, during an infectious disease, after using antibiotics or if there is a clinical suspicion of the disease.

Fulminant symptoms of nonspecific ulcerative colitis

Patients need further examination in case of severe acute exacerbations. It is necessary to perform radiography of the abdominal cavity in the position on the back and in the vertical position of the body; In this case, it is possible to identify a megacolon or accumulated gas inside the lumen, completely filling the entire length of the paralytic segment of the colon as a result of loss of muscle tone. Colonoscopy and irrigoscopy should be avoided due to the risk of perforation. It is necessary to perform a general blood test, determine ESR, electrolytes, prothrombin time, APTT, blood group and cross-test for compatibility.

The patient should be monitored because of the possibility of developing peritonitis or perforation. The appearance of the symptom "disappearance of hepatic dullness" during percussion may be the first sign of free perforation, especially in patients whose abdominal symptoms of ulcerative colitis may not be expressed due to the use of high doses of glucocorticoids. Radiography of the abdominal cavity should be performed every 1 or 2 days to control the expansion of the colon, the gas inside its lumen, and the detection of free air in the abdominal cavity.

Diagnosis of nonspecific ulcerative colitis

Treatment of ulcerative colitis

General treatment of ulcerative colitis

The exclusion of raw fruits and vegetables limits the trauma of the inflamed mucosa of the colon and can reduce symptoms. Elimination of milk from the food can be effective, but should not be continued if there is no effect. Loperamide orally 2.0 mg 2-4 times a day is indicated with a relatively mild diarrhea; higher doses for oral administration (4 mg in the morning and 2 mg after each bowel movement) may be required for more intensive diarrhea. Antidiarrheal drugs should be used with extreme caution in severe cases, because they can accelerate the development of toxic dilatation.

Lesions of the left flank of the colon

To treat patients with proctitis or colitis extending proximally not above the splenic angle, enemas with 5-aminosalicylic acid (5-ASA, mesalamine) are used once or twice a day, depending on the severity of the process. Suppositories are effective in more distal lesions and usually patients give preference to them. Clears with glucocorticoids and budesonide are less effective, but should also be used if treatment with 5-ASA is ineffective and tolerant. When remission is achieved, the dosage slowly decreases to a maintenance level.

In theory, continued oral administration of 5-ASA may be effective in reducing the likelihood of spreading the disease to the proximal colon.

Moderate or common defeat

Patients with inflammation extending proximally to the splenic angle or the entire left flank, insensitive to topical agents, should be administered oral administration of 5-ASA in addition to enemas with 5-ASA. High doses of glucocorticoids are added at more severe manifestations; After 1-2 weeks, the daily dose decreases by about 5-10 mg every week.

Severe course of the disease

Patients with a bloody stool more than 10 times a day, tachycardia, high fever and severe abdominal pain should be hospitalized for intravenous treatment with high doses of glucocorticoids. Treatment of ulcerative colitis with 5-ASA can be continued. An intravenous fluid transfusion is necessary for dehydration and anemia. Patients should be supervised to monitor the development of the toxic megacolon. Parenteral elevated nutrition is sometimes used as a food aid, but it does not matter at all as a primary therapy; Patients who do not have intolerance to food should be fed orally.

Patients who do not have the effect of treatment for 3-7 days are shown intravenous administration of cyclosporins or surgical treatment. When the treatment is effective, patients are transferred for approximately one week to oral prednisolone at 60 mg once a day, and, depending on the clinical effect, the dose can be gradually reduced when transferred to outpatient treatment.

Fulminant colitis

With the development of fulminant colitis or with suspected toxic megacolon:

1. all antidiarrheal drugs are excluded;
2. forbidden food intake and intestinal intubation with a long probe with periodic aspiration;
3. an active intravenous transfusion of liquids and electrolytes is prescribed, including a 0.9% solution of NaCI and potassium chloride; if necessary, blood transfusion;
4. intravenously high doses of glucocorticoids and
5. antibiotics (eg, metronidazole 500 mg intravenously every 8 hours and ciprofloxacin 500 mg IV every 12 hours).

The patient must be turned in the bed and change the position with a turn on the abdomen every 2-3 hours in order to redistribute the gas through the colon and prevent the progression of swelling. It may also be effective to use a soft rectal tube, but manipulation should be carried out extremely carefully so as not to cause perforation of the intestine.

If intensive therapy does not lead to significant improvement within 24-48 hours, surgical treatment is necessary; otherwise the patient may die from sepsis as a result of perforation.

Supportive therapy for ulcerative colitis

After effective treatment of exacerbation, the dose of glucocorticoids decreases and, depending on the clinical effect, is canceled; they are ineffective as a supporting therapy. Patients should take 5-ASA orally or rectally, depending on the location of the process, since the interruption of maintenance therapy often leads to a relapse of the disease. The intervals between rectal administration of the drug can be gradually increased up to 1 time in 2-3 days.

Patients who can not abolish glucocorticoids should be transferred to azathioprine or 6-mercaptopurine.

Surgical treatment of nonspecific ulcerative colitis

Almost one-third of patients with advanced ulcerative colitis ultimately need surgical treatment. Total colectomy is a cure method: life expectancy and quality of life are restored to a statistical norm, the disease does not recur (unlike Crohn's disease) and the risk of developing colon cancer is eliminated.

Emergency colectomy is indicated with massive bleeding, fulminant toxic colitis, or perforation. Subtotal colectomy with ileostomy and suturing of the rectosigmoid end of the intestine or fistula are common procedures of choice, as most patients who are in critical condition will not be able to tolerate a more extensive intervention. Recto-sigmoid fistula may be later closed or used to form an ileorektal anastomosis with an isolated loop. An intact portion of the rectum can not be left indefinitely without control because of the risk of disease activation and malignant degeneration.

Elective surgery is indicated for a high degree of mucosal dysplasia, confirmed by two pathologists, overt cancer, clinically pronounced stricture of the entire intestine, growth retardation in children or, most often, severe chronic disease leading to disability or dependence on glucocorticoids. Sometimes severe, associated with colitis, extraintestinal manifestations (eg, gangrenous pyoderma) are also an indication for surgical treatment. The selective procedure of choice in patients with normal sphincter function is a reductive proctocollectomy with the imposition of ileorektal anastomosis. This operation creates an intestinal reservoir in the pelvis or bag from the distal ileum that connects to the anus. An intact sphincter retains a blocking function, usually with 8-10 bowel movements a day. Inflammation of the bag created is a consequence of the inflammatory response observed after this intervention in approximately 50% of patients. This is believed to be associated with excessive bacterial growth and is subject to antibacterial treatment (eg, quinolones). Probiotics have protective properties. Most cases of inflammation of the bag are well treatable, but in 5-10% of cases there is no effect due to intolerance to drug therapy. Alternative surgical methods include ileostomy with an intestinal reservoir (by cots) or, more often, traditional ileostomy (according to Brooke).

Physical and psychological problems associated with any method of colon resection should be resolved, and care must be taken to ensure that the patient complies with all the recommendations and receives the psychological support necessary before and after the operation.

Treatment of ulcerative colitis

What prognosis does ulcerative colitis have?

Usually ulcerative colitis proceeds chronically with relapses of exacerbations and remissions. In approximately 10% of patients, the first attacks of the disease develop acutely with massive bleeding, perforation or sepsis and toxemia. Complete regeneration after a single episode is observed in 10%.

In patients with localized ulcerative proctitis, the prognosis is more favorable. Severe systemic manifestations, intoxication complications and neoplastic regeneration are unlikely, and in the long-term period, the spread of the disease is observed only in about 20-30% of patients. Surgical intervention is rarely required, and life expectancy is within the statistical norm. The course of the disease, however, may prove to be stubborn and less susceptible to treatment. In addition, since the common form of ulcerative colitis can begin with the rectum and progress proximally, the proctitis can not be regarded as a limited process for more than 6 months. The limited process, which later progresses, is often heavier and more intolerant to treatment.

Colon cancer

The risk of developing colon cancer is proportional to the duration of the disease and the extent of the colon lesion, but not necessarily the activity of the disease. Cancer usually begins to appear 7 years after the onset of the disease in patients with advanced colitis. The total likelihood of cancer is approximately 3% in 15 years from the onset of the disease, 5% in 20 years and 9% in 25 years, with an annual risk of cancer increasing by about 0.5-1% after 10 years of the disease. Most likely, the risk of developing cancer among patients with colitis from childhood is absent, despite a longer period of the disease.

Regular colonoscopy, preferably during remission, is indicated for patients with a disease duration of more than 8-10 years (excluding isolated proctitis). Endoscopic biopsy should be performed every 10 cm along the entire length of the colon. Any degree of established dysplasia within the affected area of the colitis is prone to progression to more severe neoplasia and even cancer and is a strict indication for total colectomy; If the dysplasia is strictly limited to a single zone, the polyp is completely removed. It is important to differentiate established neoplastic dysplasia from reactive or secondarily regenerative atypia in inflammation. However, if dysplasia is clearly defined, delayed colectomy in favor of follow-up is a risky strategy. Pseudopolypes have no prognostic significance, but can be difficult in differential diagnosis with neoplastic polyps; thus, any suspicious polyp is subject to excisional biopsy.

The optimal frequency of colonoscopic observation is not defined, but some authors recommend a study every 2 years for 2 decades of the disease and then annually.

Long-term survival after the established diagnosis of cancer associated with ulcerative colitis is approximately 50%, which is comparable overall with colorectal cancer in the general population.

[9], [10], [11], [12], [13], [14], [15], [16]